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The malpractice insurer for Canadian doctors has paid out tens of millions of dollars to families for botched deliveries that left at least 25 babies and two mothers dead and untold numbers of children disabled.

The Canadian Medical Protective Association reviewed 169 lawsuits and college complaints involving obstetrical emergencies over the past decade, including 50 cases that closed in 2010-14, “nearly all of which involved serious patient harm.”

The review included instances of doctors who showed a “serious lack of judgment” by not reacting sooner to abnormal changes in fetal heart rate, accusations of intimidation that kept nurses and residents from speaking up, “chaotic” labour wards, communication breakdowns and senseless delays getting fetuses in distress out of the womb.

The review looked at catastrophic deliveries in Canadian hospitals involving babies born in 2005-14. While it does not name doctors or families, or give the amount of settlements, it highlights a lack of “situational awareness” — meaning knowing what’s going on, and what’s likely to happen next — as a factor in many of the tragedies.

In the most serious cases, at least 25 newborns died. The CMPA refused to provide details of their deaths, citing patient confidentiality and the “professional integrity” of the doctors involved.

With obstetrics, ‘when the outcomes are bad, they’re awful’

One mother died from a post-partum hemorrhage, the other from a cerebral hemorrhage. “It is important to note that the cause of these outcomes are multi-factorial and not solely a result of the care provided,” the CMPA said.

Among the findings were missed signs of an impending uterine rupture — a rare but disastrous complication that can kill the mother, the baby, or both, or leave a child with irreversible brain damage.

Uterine ruptures are a known risk for women attempting a vaginal birth after a cesarean section (VBAC). The surgical scar can, in rare cases, pull apart.

The review highlights cases where signs of uterine “dehiscence” — part, or all, of the old surgical wound starts to come apart — were missed.

If a uterine scar separates and the cervix is not fully dilated, the fetus is expelled into the abdominal cavity. If the placenta peels away from the uterine wall, the fetus loses its oxygen supply. Babies end up with brain damage leading to cerebral palsy.

“In a rupture situation, the pain is just non-stop,” said Paul McGivern, a Vancouver lawyer whose practice over the last several decades has focused on birth injuries.

In June, a B.C. Supreme Court judge awarded McGivern’s client $5.2 million in damages for brain damage she suffered when her mother experienced a uterine rupture.

According to the judgment, critical minutes were lost when the nurse and resident didn’t consider the possibility of a rupture — even though the mother had had a C-section and was experiencing such severe pain between contractions she vomited.

Her daughter, now 16, doesn’t have the fine motor skills to do up buttons or fasten clasps. She stumbles and trips because of her disability, and flaps her arms when she gets excited or nervous. She will never be able to live independently.

While her case was not part of the CMPA review, others involved a baby dying soon after a traumatic vaginal deliver, despite an abnormal heart rate that “should have alerted the obstetrician to the need for a caesarean section two hours before the baby was ultimately delivered.”

Catastrophic deliveries are rare: in Canada, there are about six maternal deaths for every 100,000 deliveries. About five babies die per 1,000 live births.

However, with obstetrics, “when the outcomes are bad, they’re awful,” said the CMPA’s associate executive director, Dr. Douglas Bell. “They’re a tragedy for the family involved and for the infants.”

With uterine ruptures, “unfortunately the woman’s forehead doesn’t flash the sign that says, ‘my uterus is rupturing,’ and it could be quite minimal — you see some subtle changes in the fetal heart rate, or there’s a little bit unusual pain pattern,” said Bell, a former obstetrician.

“The trouble is, all laboring women have pain, but they complain the pain is different. And that’s where you need to be able to put that together and say, ‘We better make sure what’s going on here and react to what’s happening.’ ”

But McGivern said he sees the same problems time again. “Physicians and nurses just get kind of inured to the symptoms that they should be looking for,” he said.

Ottawa lawyer Arthur Cogan has obtained multimillion-dollar birth injury settlements in cases where, had the baby been delivered 12 to 15 minutes sooner by a “crash” C-section, it would have meant the difference “between being normal, and quadriplegic.”

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